State of Wisconsin Forms in Microsoft Word

PRACTITIONER’S REPORT ON ACCIDENT OR INDUSTRIAL DISEASE IN LIEU OF TESTIMONY

$12.99

WKC-7

Hearing Application

$12.99

WKC-3-E

Medical Treatment Statement — For listing charges from medical providers, or for medicine and supplies.

$12.99

WKC-7-B

Compromise Review Application

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WKC-12-E

Employer’s First Report of Injury or Disease — This is a Word file that is protected from modification and enabled for form fill (includes tabbed fields for form completion).

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WKC-13-E

Supplementary Report on Accidents and Industrial Diseases — Supplemental report to be filed by the insurer or self-insured employer when payments are started, stopped, suspended or changed.& This version is protected from modification and enabled for form fill (includes tabbed fields for form completion).& This is a Word document.

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WKC-13A-E

Wage Information — To be filed with the Department by the insurer or self-insured employer when wage used is less than the maximum compensation rate.& This version is protected from modification and enabled for form fill (includes tabbed fields for form completion).& This is a Word document.

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WKC-16-E

Medical Report on Industrial Injuries — To be filed by the insurer or self-insured employer when temporary disability exceeds 3 weeks or permanent disability results.

Practitioner’s Report on Accident or Industrial Disease in Lieu of Testimony& Printable version&&

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WKC-17

Subpoena

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WKC-19-E

Admission to Service and Answer to Application — To be filed by the respondent insurer or employer with the Department and the party filing application for hearing. Must be filed within 20 days after service of the application to the Department

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WKC-28

Labor and Industry Review Commission Petition for Review of Findings and Order of Administrative Law Judge — To be used by a party to appeal administrative law judge’s order to the Labor and Industry Review Commission.

$12.99

WKC-34

License Application

$12.99

WKC-35

WC Hearing Appearance Permit Application

$12.99

WKC-140

Supplemental Payments Reimbursement Request

$12.99

WKC-170

Third Party Proceeds Agreement — To be filed by the insurance carrier with the Department for approval of distribution.

$12.99

WKC-176

Compromise Agreement — To be filed by the parties with the Department for approval of compensation resolving a dispute.

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